FS FORM 28b, NOV 2016 (EQUAL EMPLOYMENT OPPORTUNITY OFFICE)

DISPOSITION OF REASONABLE ACCOMMODATIONS REQUEST

FIRST: MI: LAST:

PREVIOUS EDITIONS ARE OBSOLETE PAGE 1 OF 5

AUTHORITY: 29 U.S.C. Section 791; 29 C.F.R. Part 1614; see 20 C.F.R. part 1630. PRINCIPAL PURPOSE: The information requested is for the purpose of gathering information related to the request for reasonable accommodations. Further, Executive Order 13164 mandates that Federal agencies have written procedures for proving reasonable accommodation and maintain records in order to monitor the effectiveness of the procedures. ROUTINE USES: Solely used to gather information related to your request for reasonable accommodations. DISCLOSURE: Completion of this form is voluntary. However, no accommodations may be given to a qualified individual without written information. Contents shall not be disclosed, discussed, or shared with individuals unless they have a direct need-to-know in performance of their official duties. Deliver this document directly to the intended recipient. DO NOT drop off, send to an unauthorized third-party or send via e-mail un-encrypt. Sending PII via regular e-mail is highly discouraged. Regular e-mail is sent "in the clear" and therefore is subject to interception by hackers. There are many other options for sending private, sensitive information or PII securely through e-mail. Please research these options and use them accordingly. This document contains personal or privileged information and should be treated as "For Official Use Only (FOUO)".

DATA REQUIRED BY THE PRIVACY ACT OF 1974

1. This form is to be completed by the supervisor or Deciding Official accompanied with the employee's original request, FS Form 28a - Request for Reasonable Accommodations.

2. Please complete the entire form, sign the form (digitally if available) and send to the Disability Program Manager (EEO Office) preferably via e-mail by selecting the "Submit via e-Mail" button at the bottom on any page and following the prompts.

3. If you cannot send the form utilizing the "Submit via e-Mail" prompts, please save the form to your computer and e-mail, mail or hand carry the form utilizing any of the following addresses or fax below (e-mail is the most preferred method of submission).

4. This form and FS Form 28a are used for record-keeping and reporting purposes only. These forms should be maintained separately from the employee's personnel file and documents. Attach copies of all documents obtained or developed in processing this report form.

5. If additional medical information is necessary, please ensure that the employee completes DD Form 2870 (Authorization for Disclosure of Medical or Dental Information).

6. Provide a final copy of this form (FS Form 28b) and the request form (FS Form 28a) to the employee, the Disability Program Manager and your civilian personnel office.

Equal Employment Opportunity Office usarmy.sill.imcom-central.mbx.usage-eeo@mail.mil 1670 Craig Road Telephone: (580) 442-4024 Fort Sill, Oklahoma 73503 Fax: (580) 442-7205

a.

TITLE: NAME:b.

REASONABLE ACCOMMODATION(S): (Check one)

SECTION I - SUPERVISOR/DECIDING OFFICIAL

INSTRUCTIONS:

DPM REQUEST LOG NUMBER: REQUEST LOG DATE:

AGENCY/DIRECTORATE NAME:

***FOR EEO OFFICE USE ONLY***

NAME AND TITLE OF INDIVIDUAL REQUESTING REASONABLE ACCOMMODATIONS:

AGENCY/DIRECTORATE OF REQUESTING INDIVIDUAL:

c. APPROVED

DENIED (If denied, attach copy of the written denial letter / memorandum stating reason)

DESCRIBE THE TYPE OF ACCOMMODATION(S) REQUESTED:d.

DPM SIGNATURE: DPM SIGNATURE DATE:

APPROVED WITH MODIFICATIONS (See block "e")

FS FORM 28b, NOV 2016 (EQUAL EMPLOYMENT OPPORTUNITY OFFICE)

DISPOSITION OF REASONABLE ACCOMMODATIONS REQUEST

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e.SECTION I - SUPERVISOR/DECIDING OFFICIAL (CONTINUE)

DATE REASONABLE ACCOMMODATION(S) REQUEST REFERRED TO DECIDING OFFICIAL:

(e. g., Supervisor, Office or Division Director, HR Specialist etc.)

f.

TITLE AND NAME OF DECIDING OFFICIAL:g.

LAST:MI:FIRST:NAME:TITLE:

DATE REASONABLE ACCOMMODATION(S) APPROVED OR DENIED:h.

DATE OF DISPOSITION OF THE REASONABLE ACCOMMODATION(S) REQUEST: (if different from date approved):

i.

INTERIM MEASURES PROVIDED, if any:j.

DESCRIBE THE TYPE OF ACCOMMODATION(S) GRANTED (if different from what was requested):

FS FORM 28b, NOV 2016 (EQUAL EMPLOYMENT OPPORTUNITY OFFICE)

DISPOSITION OF REASONABLE ACCOMMODATIONS REQUEST

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IF TIME FRAMES OUTLINED FOR REASONABLE ACCOMMODATION PROCEDURES, WERE NOT MET, PLEASE EXPLAIN:k.

ACCOMMODATION INEFFECTIVE MEDICAL DOCUMENTATION INADEQUATE ACCOMMODATION WOULD CAUSEUNDUE HARDSHIP

ACCOMMODATION WOULD REQUIRE REMOVAL OF AN ESSENTIAL FUNCTION OR OTHERWISE WOULD REQUIRE LOWERING OF

SECTION I - SUPERVISOR/DECIDING OFFICIAL (CONTINUE)

REQUEST FOR REASONABLE ACCOMMODATION(S) DENIED BECAUSE: (You may check more than one box)l.

PERFORMANCE OR PRODUCT STANDARD

DETAILED REASON(S) FOR THE DENIAL OF REASONABLE ACCOMMODATION(S). MUST BE SPECIFIC, (e.g., why accommodation would be ineffective or cause undue hardship).

m.

FS FORM 28b, NOV 2016 (EQUAL EMPLOYMENT OPPORTUNITY OFFICE)

DISPOSITION OF REASONABLE ACCOMMODATIONS REQUEST

WAS MEDICAL INFORMATION REQUIRED TO PROCESS THIS REQUEST?n.SECTION I - SUPERVISOR/DECIDING OFFICIAL (CONTINUE)

YES NO

SOURCES OF TECHNICAL ASSISTANCE, IF ANY, CONSULTED IN TRYING TO IDENTIFY POSSIBLE REASONABLE ACCOMMODATIONS (e.g., Job Accommodation Network, disability organization, Reasonable Accommodation Coordinator).

o.

COMMENTS:p.

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FS FORM 28b, NOV 2016 (EQUAL EMPLOYMENT OPPORTUNITY OFFICE)

DISPOSITION OF REASONABLE ACCOMMODATIONS REQUESTSECTION II - CERTIFICATION AND CONSENT BY DECIDING OFFICIAL

I certify that all statements made above are true to the best of my knowledge and belief.

DECIDING OFFICIAL SIGNATURE: DATE PHONE NUMBER

e-MAIL:

FOR MORE INFORMATION PLEASE CONTACT: EQUAL EMPLOYMENT OPPORTUNITY OFFICE ATTENTION: DISABILITY PROGRAM MANAGER 1670 CRAIG ROAD FORT SILL, OKLAHOMA 73503 (580) 442-4024 IF THE REQUESTOR IS NOT SATISFIED WITH THIS DECISION, HE/SHE MAY DO THE FOLLOWING: a. Direct a request for reconsideration to the person who issued the decision (the Deciding Official) in response to your request, or to a supervisor in that person's chain of command. Your request for reconsideration must be delivered no later than 30 business days from the date you received your decision. Please include a copy of the decision issued to you with your request and additional information or arguments you choose to submit. b. If an individual wishes to file an Equal Employment Opportunity (EEO) complaint, or pursue Merit Systems Protection Board Request (MSPB) or union grievance procedures, he/she must take the following steps: (1) For an EEO complaint, contact the EEO office within 45 days of receipt of the decision; (2) For an MSPB appeal, file within 30 days of an action that is appealable to the board; or (3) For a collective bargaining claim, file a written grievance in accordance with appropriate grievance procedures. Special Note: Each grievance/complaint procedure(s) timelines run congruently as of the date of the decision. In other words, timelines for the above procedures start on the date decision and do not hold for another filed procedure.

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